Shifrin~Hayworth
Healthcare Professional Registration Form

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Pharmaceutical and other healthcare product and service companies must understand the needs of professionals like yourself in order to successfully bring effective and useful products to healthcare providers and patients. To understand these needs, companies conduct market research studies. These studies take many forms, including one-on-one interviews, telephone interviews, Internet surveys, and focus groups. Studies typically last from 30 minutes to 2 hours and pay anywhere from $100 to $400 depending on the client, length and topic. One way in which we serve our clients is by asking people like you to give their opinions. Our clients need your opinions and they are willing to pay you for them.

When you register to participate in our marketing research studies, your information is placed in our confidential database. Your participation will not result in any sales efforts by our client. We will then contact you when we have a study that we'd like to pay you to participate in. Before giving us any information, please read our privacy statement.

If you are not comfortable with providing this information online, we can send you a form in the mail to fill out and return to us. All you need to do is contact us. If you do this, all the information you need to give us is your name and address for us to mail the form to you. Please also specify that you want our Healthcare Professional database form or our Consumer database form or both.

Michigan Only

Professional Information
First Name:   Last Name:  
Specialty 1:
Specialty 2:
Specify Other:
Specify Other:
Date you completed your residency: (MM/DD/YY) 
 
Personal Information
Sex:  Male Female Birth Date (MM/DD/YY):  
Address:   City:  
State or Province:  
Zip/Postal Code:   Email:  
Please state all phone numbers in the form of the example: (000) 123-4567
Phone 1:  
Ext:  
Phone 2:  
Ext:  
Fax:   Pager:  

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